Heart Failure (pathology)

Question 1

What is heart failure?

Answer 1

Heart cannot pump blood from both left and right ventricles

Question 2

What is the outcome of heart failure?

Answer 2

↓ CO and GFR = perceived as decrease in plasma volume —> ↑ Na and H2O (RAAS) + vasoconstriction (SNS) = ↑ plasma volume = heart dilates = ↓ contractility = ↓ CO-> RAAS+ SNS

Question 3

What is the outcome of left heart failure?

Answer 3

↑pressure in the lungs = pulmonary oedema with transudate – crackles, tachycardia

Question 4

What causes left heart failure?

Answer 4

Product of LV injury (coronary artery disease, hypertension, cardiomyopathy, valve disease)—> remodelling —> dysfunction —> decreased plasma volume—> induce RAAS+ sympathetic NS

- Salt and water retention
- Hypokalaemia + hypomagnesaemia= arrhythmogenic 
- Vasoconstriction

Question 5

What is the outcome of right heart failure?

Answer 5

Right heart failure—> blood back into systemic circulation= peripheral oedema + liver central venous congestion (hepatomegaly, peripheral oedema, ↑ JVP, nutmeg liver)

Due to increased hydrostatic pressure (pushing fluid out of capillaries)

Question 6

Heart failure not a final diagnosis, What underlying causes lead to heart failure?

Answer 6

• Chronic HF due to left ventricular systolic dysfunction (LVSD) due to ischemic heart disease (IHD)
• HF due to severe aortic stenosis

Question 7

What are the types of heart failure?

Answer 7

• Left ventricular systolic dysfunction (HFrEF)->impaired pumping- reduced ejection fraction
• Left ventricular diastolic heart failure (HFpEF)= impaired filling-preserved ejection fraction- thickened cardiac muscle

Question 8

What are the risk factors for heart failure (4)?

Answer 8

• Age
• More common in females
• Hypertension -> diastolic dysfunction-> systolic dysfunction
• MI-> directly systolic dysfunction

Question 9

What causes LVSD?

Answer 9

• MI
• Dilated cardiomyopathy (inherited, toxins, Lyme disease, systemic disease, high BP)
• Aortic disease or mitral regurgitation

Question 10

Causes of heart failure (6)?

Answer 10

• Valvular disease
• Pericardial constriction/effusion
• Cardiac arrhythmias (tachy/brady)
• MI
• Restrictive cardiopathy
• Right heart failure (primary or secondary to pulmonary hypertension)

Question 11

What are the symptoms of heart failure (4)?

Answer 11

• SOB
• Fatigue
• Peripheral Oedema
• Reduced exercise capacity

Question 12

What are the signs of heart failure (7)?

Answer 12

• Oedema
• Tachycardia
• ↑ JVP
• Chest crepitations or effusions
• 3rd heart sound
• Displacement or abnormal apex beat
• Hepatomegaly

Question 13

What are the 4 grades of the NYHA classification of heart failure?

Answer 13

NYHA classification of HF

• 1 no exercise limitation/ no symptoms
• 2 mild exercise limitation/ comfortable with rest-mild exertion
• 3 moderate exercise limitation/comfortable only at rest
• 4 severe limitation/any activity brings discomfort/ symptoms at rest

(Grading also based on degree of LV impairment/ valve dysfunction + elevation of BNP)

Question 14

How is heart failure diagnosed?

Answer 14

1) Symptoms + signs of HF (rest or exercise)
+
2) Objective evidence of cardiac dysfunction
3) Response to therapy -Diuretics (FUROSEMIDE)

Question 15

Which Objective evidence of cardiac dysfunction investigations are used to diagnose heart failure?

Answer 15

• Echocardiography -ESSENTIAL
• Radionuclide ventriculography (RNVG, MUGA)
• MRI
• Left ventriculography In doubtful cases

Question 16

What % ranges does heart failure range from normal to severe on an echocardiography?

Answer 16

Normal 55-70%
Mild 40-55%
Moderate 30-40%

Severe < 30%

Question 17

What screening tests are the FIRST line for suspected Heart failure?

Answer 17

• BNP
  
  • ↑BNP= seen in HF= need for echo/cardiac assessment, ↓BNP= exclude HF
• Exclude renal failure, anaemia, thyroid disease (TFTs) electrolytes, autoantibodies, ferritin, serology
• Coronary angio if chest pain

Question 18

What is the difference between HFrEF and HFpEF?

Answer 18

Both due to LVSD
HFrEF = heart failure with reduced ejection fraction (also known as systolic HF)
HFpEF = heart failure with preserved ejection fraction (diastolic HF)

Question 19

What is the treatment of heart failure due to LVSD (HFrEF)?

Answer 19

*diuretics in both HFrEF & HFpEF

1 ACE inhibitors (RAMIPRIL) + Beta blockers – only use if patient is stabilised, not in acute HF
- ARBs (no reduction in mortality) if intolerant to ACEi
2 Mineralocorticoid receptor antagonists – SPIRONOLACTONE / EPLERENONE – recommended for ALL HFrEF LVEF ≤ 35% + ACEi & BBs if symptoms continue
3 Angiotensin receptor and neprolysin inhibitor (ARNI)= blocks breakdown of BNP+ boosts endogenous BNP
- VALSARTAN-SACUBITRIL
4 IVABRIDINE (If channel blocker)- only use if stable rhythm and HR ≥ 70
5 DIGOXIN- ↑ Ca2+. In myocytes -> reduce hospitalisation but no effect on mortality

Question 20

What is the treatment of heart failure due to LVSD (HFpEF)?

Answer 20

• Manage comorbidities (hypertension, atrial fibrillation, IHD, diabetes)

Question 21

What is monitored closely in heart failure?

Answer 21

Weight

Regular monitoring of weight to determine loss/gain of fluid